® Value Based Purchasing Puts Pressure on AMC’s to Perform The IQ Program Provides Solutions Julie Cerese, RN, MSN Vice President, Performance Improvement April 4, 2011 © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 1 Value Based Purchasing is Here Proposed Clinical Measures AMI-2 Aspirin prescribed at discharge SCIP-Inf-1 Prophylactic antibiotic received within 1 hour prior to surgical incision AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival SCIP-Inf-2 Prophylactic antibiotic selection for surgical patients AMI-8a Primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital arrival SCIP-Inf-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time HF-1 Discharge instructions HF-2 Left ventricular function assessment HF-3 ACE-I or ARBs for left ventricular systolic dysfunction SCIP-Inf-4 Cardiac Surgery patients with controlled 6AM postoperative serum glucose SCIP-Card- 2 Surgery pts on a beta blocker prior to arrival that receive beta blocker during the periop period PN-2 Pneumococcal vaccination status SCIP-VTE-1 VTE prophylaxis ordered for surgery patients PN-3b Blood culture performed before first antibiotic received in hospital SCIP-VTE-2 VTE prophylaxis within 24 hours pre/post surgery PN-6 Appropriate antibiotic selection PN-7 Influenza vaccination status Scoring will be based on achievement or improvement © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 2 Clinical Care Scores Vary Widely Among AMCs % of clinical process of care domain score earned (Achievement Scores Only) 100% 80% 75th Percentile Nationally 60% 40% 25th Percentile Nationally 20% 345 56 78 54 395 29 218 38 336 96 58 74 163 4 72 6 97 52 79 32 14 46 80 17 214 8 92 179 67 236 42 3 15 26 5 1 234 346 11 61 47 12 240 60 40 43 10 37 274 9 45 69 28 167 57 70 82 34 291 84 53 13 48 55 486 35 23 7 810 91 83 299 89 87 39 27 180 33 71 2 388 526 49 21 88 76 77 368 222 525 66 22 16 290 73 19 90 298 0% NOTE: Includes UHC Full Members Source: CMS Hospital Compare Q2 2009 – Q1 2010 (Apr 09 – Mar 10) © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 3 Proposed HCAHPS Measures • Nurse Communication • Doctor Communication • Pain Management • Communication about Medications • Cleanliness and Quietness of Hospital Environment (average of the 2 rees) • Responsiveness of Hospital Staff • Discharge Information • Overall Rating of Hospital (excludes recommend hospital item) © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 4 Similar Findings Across HCAHPS Scores % of satisfaction domain score earned (Achievement Scores Only) 100% 75th Percentile Nationally 80% 60% 25th Percentile Nationally 40% 20% 97 96 9 78 39 163 21 180 8 37 19 218 395 33 91 6 47 84 13 66 79 53 240 336 22 48 290 525 32 11 72 43 54 38 61 73 16 34 26 92 60 10 810 179 71 67 29 222 526 274 52 12 2 346 42 15 7 3 56 55 368 291 23 35 5 90 17 14 486 46 1 45 76 214 57 82 236 4 70 234 27 298 388 167 80 77 89 40 58 83 87 49 88 69 299 28 74 345 0% NOTE: Includes UHC Full Members Source: CMS Hospital Compare Q2 2009 – Q1 2010 (Apr 09 – Mar 10) © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 5 Total VBP Performance Scores % of total VBP performance score earned (Achievement Scores Only) 100% 80% 75th Percentile Nationally 60% 25th Percentile Nationally 40% 20% 78 54 395 218 56 96 336 163 38 29 97 6 72 79 32 52 8 14 46 4 17 92 179 67 214 58 47 240 9 37 11 26 43 61 42 80 3 60 10 15 346 12 345 274 5 236 34 84 53 1 13 48 291 45 234 91 74 39 57 810 55 180 33 82 7 70 23 35 486 71 40 167 21 2 526 27 525 89 66 222 388 83 69 368 22 28 87 76 290 19 16 73 49 299 77 88 90 298 0% Notes: 1) VBP Performance Score determined based on weighted average of clinical process of care score (70%) and HCAHPS score (30%) 2) Includes UHC Full Members Source: CMS Hospital Compare Q2 2009 – Q1 2010 (Apr 09 – Mar 10) © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 6 VBP Financial Impact • Initially, all hospitals will lose 1% of their Medicare payments (in 2013). • A hospital’s VBP score determines how much of that 1% they can earn back. • Top performers (nationally) have the potential to earn back their initial 1% and more. • CMS intends to use a “linear exchange function” to determine how much each hospital earns back₁ 1 CMS has not yet defined the linear exchange function they will employ to determine VBP payments. UHC has modeled the VBP financial impact under two possible linear exchange scenarios to estimate the financial impact of a given member’s VBP score (for more details, see ‘Linear Exchange Functions’). © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 7 VBP Financial Impact 1% Medicare Reimbursement at Risk Scenario 1 High UHC Medicare Volume Medium 25th Median 75th Low Scenario 2 High Medium 1% Recovered + upside Low ($3,000,000) Unrecovered VBP $ ($2,000,000) ($1,000,000) $0 Break-even $1,000,000 $2,000,000 $3,000,000 Scenario 1: continuous linearity from 0th to 100th percentile *n = 98 Scenario 2: linearity, 25th - 75th percentiles; max penalty 0-25th percentile; max incentive 75-100th percentile Medicare Volume Discharge Thresholds: Low < 6,700; Medium 6,700 – 12,000; High < 12,000 *In this analysis, 30 UHC members fully recover their 1% incentive payment and get an additional payment (green = upside payment) © 2010 University HealthSystem Consortium $0 on the graphs above indicates that a hospital fully recovers 1% of Medicare payment (break even) VBP Scores IQ 9-10 8 More Stick Than Carrot • Performance must be at exceptional levels or demonstrate remarkable improvement in order to obtain the highest scores • One failure in a measure with a small sample size can cost significant points • AMCs less likely to fall into bottom quartile in core measures…also less likely to be among top quartile • Two-thirds of AMCs below median for patient satisfaction . One in three AMCs in bottom quartile– fewer than 10% make top quartile However there are top performers among AMC’s © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 9 9 AMC Focus Identified: UHC’s Imperatives for Quality Capacity Management Mortality HospitalAcquired Conditions Core Measures / CAHPS Cost Reduction © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 10 10 AMC Opportunities for Improvement Identified in IQ Program Core Measure UHC Best Quartile UHC Best Decile National Best Decile AMI 98.2% 100.0% 100%% HF 93.3% 97.1% 99.8% PN 85.4%* 90.0% 99.3% SCIP 90.0% 92.6% 99.4% AMC Opportunities D2B, Smoking D/C Instructions Vaccines, Abx timing Beta blocker. ABX dcd, normothermia “ensure that members are nationally recognized for their leadership in safety, quality, and costeffectiveness” © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 11 11 IQ Offers Practical Improvement Resources AMI: Door-to-Balloon Best Practice Staff arrival requirement is < 30 minutes after the initial page (both in-house and on-call staff) Best Practice EKG performed by emergency medical services triggers emergency department action © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 12 Traditional Elements of D2B: Parallel Process Chest Pain EMS Transport Registration ECG MD Eval Int. Cardiol. STEMI Team Call for Pt PCI © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 13 ST Segment Elevation Myocardial Infarction (STEMI) UMMHC Process Improvement: 2005-YTD 160 Cardiac Alert Team Initiative Began Critical Success Factors - Communication Overhaul - ED Activation of cath lab - Real time review of STEMI cases - Reserved parking for on-call staff 140 100 (minutes) Door to Balloon Time 120 80 60 40 20 0 Jan'05 Jun'05 Nov'05 Apr'06 Sep'06 Feb'07 Jul'07 Median Number of Cases CY2005: 55 CY2009: 117 CY2006: 62 Mean CY2007: 89 CY2010: 92 Dec'07 M ay'08 Oct'08 M ar"09 Aug'09 Jan'10 Jun'10 Goal © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 14 CY2008 : 82 Nov"10 Heart Failure Discharge Instructions Doesn’t Require Sophistication, Just Determination Measures Required • Diet • Activity • Medications • What to do if symptoms worsen • Follow up • Weight Monitoring Critical Success Factors • Redesign discharge form; keep it SIMPLE • EHR hard stop • Share unit-based rates • Share performance with Board of Directors • Concurrent Review – individual feedback • Focus on non-compliant areas • When all else failed – disciplinary action © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 15 Pneumonia: Improving Vaccination Rates Pneumococcal Vaccine Compliance Why it works • Automated admit and transfer out of ICU order sets were developed, • Nurse responsible to screen and administer the vaccine if the patient met criteria • Staff were well-educated on the new process • Process is built into the nurses daily routine • Performance was an expectation and became part of the culture • Screening tool is user-friendly 100% 90% 80% Vaccine Process Implemented 4Q 07 70% 60% 50% 1Q06 3Q06 1Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 Influenza Vaccine Compliance 100% 90% 80% Vaccine Process Implemented 4Q 07 70% 60% 50% 1Q06 4Q06 1Q07 4Q07 1Q08 4Q08 1Q09 4Q09 1Q10 *Compliance rates only collected during flu season (4Q - 1Q) © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 16 SCIP: Multiple Measures Call for Multidisciplinary Effort SCIP Process Measures • SCIP-Inf-1: Prophylactic antibiotic timing • SCIP-Inf-2: Prophylactic antibiotic administration • SCIP-Inf-3: Prophylactic antibiotic discontinuation • SCIP-Inf-4: Post-op Serum Glucose (Cardiac) • SCIP-Inf-6: Hair Removal • SCIP-Inf-7: Post-op Normothermia (Colorectal) • SCIP-Card-2: Beta-blocker administration • SCIP-VTE-1: VTE Prophylaxis ordered • SCIP-VTE-2: VTE Prophylaxis administered Focused Perioperative Interventions to Improve Performance • Team effort to identify gaps in process • Developed tools to improve antibiotic ordering and dosing (standardized order sets, signage) • Included antibiotic selection in “Time Out Process,” • Improve availability of antibiotics • Educated Surgeons, Anesthesia Care Providers and Nursing: What are the SCIP measures and why are they important? • Communicated and reinforced desired behaviors © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 17 Data Distribution and Communication Helps to Maintain the Gains • Viewable on Quality & Patient Safety Web site • Shared at leadership meetings • Shared at OR committee, Anesthesia committee, Quality and Staff meetings • Emailed to Division Chairs/Chiefs and Residents • Displayed in Staff areas • Letters and education mailed to failed case physicians (infection measures) © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 18 Study of Top HCAHPS Performers Reveals Critical Success Factors • Leaders communicate to inform, inspire, and promote healthy competition UC San Diego Health System • Combine commitment to quality and service Massachusetts General Hospital • Set goals and work together to achieve success University of South Alabama Health System • Customer service is ingrained in the mission and values Mayo Clinic in Rochester • Data-driven decisions are critical to the change effort University of Mississippi Health Care © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 19 19 HCAHPS: Combine Commitment to Quality & Service Massachusetts General Hospital • Used QDM data to focus improvement areas: cleanliness, communications, and responsiveness • Incentive program for employed physicians • Managerial goals tied to patient experience • Wide dissemination of performance data • RNs round on each patient hourly • Light-duty staff interview patients about satisfaction “It’s a journey, it takes a village, and it requires taking ownership, remaining focused on the goals, celebrating what’s working, fixing what’s broken, communicating and remaining committed to delivering the highest quality, safest care as defined by patients and their families.” Richard Corder, Senior Director of Service © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 20 IQ Offers Solutions for Proposed Measures for FY2014 • Three 30-day Mortality Rates (AMI, HF, Pneumonia) • 8 Hospital Acquired Conditions (foreign object retained after surgery, air embolism, blood incompatibility, pressure ulcers III&IV, falls and trauma, vascular catheter-associated infections, catheterassociated UTIs, manifestations of poor glycemic control) • 9 AHRQ Patient Safety Indicators (PSIs) and Inpatient Quality Indicators (IQIs) • • • • • • • • • Iatrogenic pneumothorax, adult Post operative respiratory failure Post operative PE or DVT Post operative wound dehiscence Accidental puncture or laceration Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume) Hip fracture mortality rate Complication/patient safety for selected indicators (composite) Mortaility for selected medical conditions © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 21 Summary The demand for quality and safety performance and transparency is increasing Pay for performance is here Great clinical outcomes require reliable data and a culture of accountability Be prepared and anticipate the future © 2010 University HealthSystem Consortium VBP Scores IQ 9-10 22 22